ke/sb/nl/rg.
Name of the Patient : Abc Xyz Shakirulmn / F / 40 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with pain radiating to BUE with paresthesias
Alleged H/O vehicular accident 1 1/2 years back.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
OBSERVATION :
There is forward subluxation of the C5 over the C6 vertebral body with disruption of the C5-C6 facet joint and a kyphus at that level.
The postero-superior margin of the C6 vertebral body is seen to indent the anterior aspect of the spinal cord, more to the right of the midline.
A focal hypointense area on the T1 Weighted images is seen in the cervical spinal cord at the C6 vertebral level which is seen to turn hyperintense on the T2 Weighted and Fast Scan (T2 *) images and would represent myelomalacia, probably a sequelae of previous cord contusion.
Small posterior disc bulge is seen at the C3-C4 level. The cervical intervertebral discs show loss of water content.
Fatty changes are noted in the C4 and C5 vertebral bodies.
Probable fracture of the C5 spinous process/lamina is noted.
..2/.
The rest of the cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. Forward subluxation of the C5 over the C6 vertebral body with disruption of the C5-C6 facet joints and a kyphus at that level.
2. Indentation on the cervical cord by the postero-superior margin of the C6 vertebral body.
3. Area of myelomalacia at the C6 vertebral level, the sequelae of previous cord contusion.
4. Probable fracture of C5 spinous process/lamina.